Board of Directors� Nomination Form by 699qkw

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									                   NAFC Board of Directors’ Nomination Form
The National Association of Free Clinics is calling for Board Nominations from
its membership. If you are interested in running for election to fill one of the
open NAFC Board seats, please fill out this form and return to the NAFC.

Please direct questions to Nicole Lamoureux, NAFC’s Executive Director at
703-647-7427 or NLamoureux@freeclinics.us.

Name:
Title:
Clinic/
Organization:
Free Clinic
Affiliation:
Mailing
Address:
City:                                          STATE:                Zip:
Work phone:                                    Home #
Cell #:                                        Fax:
Email:
All of the above contact information is required for any nominee to be considered by the
NAFC Nominating Committee.

What would make you a unique and valuable contributor to the NAFC Board of
Directors’?
                     (Please limit your response to 500 words or less.)



Nomination Forms are due by September 9, 2011 – please email to Nicole
Lamoureux, NLamoureux@freeclinics.us




Please briefly describe three major Issues (including at least one public policy
issue) facing the free clinic community, and indicate how the NAFC might
respond.
                     (Please limit your response to 500 words or less.)
Professional References

Please list two professional references that will speak to the NAFC Nominating
committee regarding your professional performance and ability.




EMPLOYMENT, EDUCATION AND OTHER EXPERIENCE

Please attach a copy of your current resume or other documentation that outlines
your employment history, education and other information relevant to your
professional career. Please limit your attachment to no more than three (3)
pages.

Board Meeting Requirements

The NAFC Board holds three annual face-to-face meetings. One in Washington
DC, one in conjunction with the Annual Summit and one in a location hosted by a
Board Member.

The NAFC at this time, is not able to cover the cost of these meetings for its
Board members, therefore individual Board members must incur the travel and
accommodation cost for these meetings.

Please confirm that you acknowledge this notice of travel cost and individual
responsibility.

_____I have read and understood that in order to be eligible for nomination to the
NAFC Board I will incur my travel and accommodation cost for the three face to
face board meetings.

The NAFC holds monthly Board conference calls and all board members are
expected to attend this call as well as sit on at least one of the NAFC
Committees.

Please confirm that you acknowledge this notice of monthly meeting schedules.
_____I have read and understood that in order to be eligible for nomination to the
NAFC Board I will be expected to attend a monthly board conference call and a
monthly committee conference call.


Nominee’s Clinic Demographics

Number of full-time staff members employed by candidate's organization:___

Number of part-time staff members employed by candidate’s organization: ___

Number of volunteers at candidate’s organization:________________________

Annual operating revenue/budget of candidate’s organization: $_______


Nomination Forms are due by September 9, 2011 – please email to Nicole
Lamoure, NLamoureux@freeclinics.us
Skills Grid
Name: __________________________________

Experience / Skills                        Demographic
Accounting                                 Female
Alternative Medicine                       Male
Banking                                    Age:
Business / Corporate
Community Involvement                      Ethnic / Cultural
Dental                                     Asian
Education                                  African American
Human Resources                            Caucasian
Financial Planning / Management            Hispanic / Latino
Fund Development                           Native American
Government Relations                       Other
Grant Writing
Health / Medicine                          Community Board Experience
Investments                                1-3 years
Law                                        4-6 years
Marketing                                  6+ years
Mental Health
Non-Profit Management                      NAFC Committees
Pharmacy                                   C.A.R.E.
Public Relations                           Development
Technology                                 Executive
Volunteer Management                       Finance
Other CLINIC DEVELOPMENT                   Governance
                                           Legislative
Profession / Association                   Membership
Free Clinic CEO                            Summit
Free Clinic Staff
Free Clinic Volunteer                      Residence
FC State Association                       State:
FC Regional Association                    East
                                           Midwest
Connections / Influence                    Northeast
Civic Groups                               Southeast
Corporate Community                        Southwest
Ethnic / Cultural Groups                   West
Foundations
Government
Media
National Associations
Non-Profit Agencies
Pharmaceutical
Professional Groups

								
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